The

TM

EPEC-O

Education in Palliative and End-of-life Care - Oncology

Project

The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

E P E C O EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

Module 3p Symptoms – Nausea / vomiting

Nausea / vomiting . . .



Definition Nausea is an unpleasant subjective sensation of being about to vomit Vomiting is the reflex expulsion of gastric contents through the mouth

. . . Nausea / vomiting



Impact very distressing: Awareness of nausea Inability to keep food or fluids down Acid and bitter tastes Unpleasant smells of vomitus

Key points 1.

Pathophysiology 2.

Assessment 3.

Management

Pathophysiology



Nausea Subjective sensation (easily learned) Stimulation Gastrointestinal lining, CTZ, vestibular apparatus, cerebral cortex



Vomiting Neuromuscular reflex

Pathophysiology Chemoreceptor Trigger Zone (CTZ) Vomiting center Neurotransmitters



Acetylcholine



Dopamine



Histamine



Neurokinin



Serotonin Cortex Vestibular apparatus GI tract

Causes



M etastases



M eningeal irritation



M echanical obstruction



M ovement



M ental anxiety



M otility



M etabolic



M edications



M ucosal irritation



M icrobes



M yocardial

Assessment



When



Acute versus chronic



Intermittent or constant



Associated with sights or smells



Eating patterns



Bowel patterns



Medications

Management



Dopamine antagonists



Antihistamines



Anticholinergics



Serotonin antagonists



Neurokinin antagonists



Prokinetic agents



Antacids



Cytoprotective agents



Other medications

Gralla R, et al.

J Clin Oncol

, 1999.

Chemotherapy nausea



Acute < 24 hr Chemoreceptor trigger zone Serotonin release in the gut



Delayed 24 hr (may be days) Unclear mechanism

Chemotherapy emetogenicity Emetogenic Class I II III IV V Incidence acute vomiting Minimal < 10 % Low 10 – 30 % Mild 30 – 60 % Moderate 80 – 90 % High > 90 %

Dopamine antagonists



Haloperidol



Prochlorperazine



Droperidol



Thiethylperazine



Promethazine



Trimethobenzamide



Metoclopramide



Olanzapine



Perphenazine

Histamine antagonists (antihistamines)



Diphenhydramine



Meclizine



Hydroxyzine

Acetylcholine antagonists (anticholinergics)



Scopolamine

Serotonin antagonists



Ondansetron



Granisetron



Dolasetron



Palonosetron

Neurokinin-1 antagonists



Aprepitant

Prokinetic agents



Metoclopramide



Domperidone



Macrolide antibiotics, eg, erythromycin

Antacids



Antacids



H 2 receptor antagonists Cimetidine Famotidine Ranitidine



Proton pump inhibitors Omeprazole Lansoprazole

Other medications



Dexamethasone 6 – 20 mg PO daily



Tetrahydrocannabinol 2.5 – 5 mg PO tid



Lorazepam 0.5 – 2 mg PO q 4 – 6 h



Octreotide 10

m

g / hr IV / SC infusion or 100

m

g SC q 8 h for bowel obstruction

E P E C O

Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience